NURSING CARE PLAN

Patient’s Initial: ___C.S._____ Age: _73 yrs.old__ Gender: __Male__ Date Handled: _April 23, 2021___
Medical Diagnosis: _Abdominal Aortic Aneurysm______ Chief Complaint: _severe back pain_________ Clinical Area: _Emergency Department_

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective: Decreased Cardiac Short Term Goal: Independent: Short Term Evaluation:
• The patient has a Output related to After 8 hours of nursing - Asess for signs of myocardial - ECG changes help guide the After 8 hours of nursing
known AAA, which has alteration in heart rate intervention, the client will ischemia: chest pain, tachycardia, or ST- timing of interventions intervention, the goal to
been followed with yearly secondary to be able to display segment and T-wave changes on ECG display hemodynamic
abdominal ultrasound abdominal aortic hemodynamic stability stability (blood pressure
testing. aneurysm as evidenced (blood pressure and cardiac - Assess the client’s hemodynamic and cardiac output) and
• The patient has smoked by cool and clammy output) and report decreased status. Monitor for signs of decreasing - Clients with decreasing or report decreased episodes
a pack of cigarettes per extremities, heart rate episodes of dyspnea, angina cardiac output, such as tachycardia, rupturing aneurysm are of dyspnea, angina and
day for 52 yrs. of 114 bpm and blood and dysrhythmias as decreased urine output, and restlessness. hemodynamically compromised. dysrhythmias was:
• The patient has had pressure of 88/60 evidenced by: Early evaluation of warning
occasional bouts of angina mmHg. - normal heart rate signs facilitates prompt _√_ met
for the past 3 yr - normal blood pressure intervention. ___ partially met
- normal heart rhythm - Monitor vital signs frequently. ___ unmet
Objective: - to note response to activities
• The patient has a and interventions As evidenced by:
pulsating abdominal mass Long Term Goal: - Monitor cardiac rhythm continuously - normal heart rate
• The patient’s After 1-2 days of nursing - to note the effectiveness of - normal blood pressure
extremities are cool and intervention the client will be mdications or assistive devices - normal heart rhythm
clammy able to participate in - Schedule activities and assessments
activities that reduce the - to maximize rest periods Long Term Evaluation:
Vital Signs workload of the heart and - Assist with or perform self-care After 1-2 days of nursing
• HR - 114 bpm demontrate an increase in activities for client. intervention the client will
• BP - 88/68 mmHg activity tolerance as be able to participate in
evidenced by: - Increase activity levels gradually as activities that reduce the
- decreased occurrence of permitted by individual condition, noting workload of the heart and
fatigue vital sign response to activity demontrate an increase in
- decreased occurrence of activity tolerance was:
dyspnea during and after Dependent:
activities - Administer fluids, diuretics, inotropic _√_ met
drugs, antidysrhythmics, steroids, ___ partially met
vasopressors or dilator, as ordered - to support systemic and cardiac ___ unmet
 circulation
- Administer medications, as ordered As evidenced by:
- decreased occurrence
of fatigue
Interdependent/ - decreased occurrence of
Collaborative: dyspnea during and after
- Administer oxygen via mask or activities
ventilator, as indicated

- Perform periodic hemodynamic

measurements, as indicated - to increase oxygen available fpr
cardiac function

Discussion Questions

1. What are C.S.'s risk factors for AAA?

Smoking. It will damage the aortic walls, raising the likelihood of rupture as well as the development of an aortic aneurysm. The more and more you smoke or chew cigarettes, the more
likely you are to experience an aortic aneurysm.
Age. These aneurysms are most common in people over the age of 65.
Gender. Men develop abdominal aortic aneurysms much more often than women do.
2. What is the etiology of an AAA?
Hardening of the arteries (atherosclerosis). When fat and other compounds accumulate on the lining of a blood vessel, this is referred to as atherosclerosis.
High blood pressure. High blood pressure will harm and weaken the walls of the aorta.
Blood vessel diseases. There are diseases that cause inflammation of the blood vessels.
Infection in the aorta. An abdominal aortic aneurysm may be caused by a bacterial or fungal infection in rare cases.
Trauma. A car crash, for example, can result in abdominal aortic aneurysms.

3. Which signs or symptoms make the nurse suspect that C.S.'s AAA has ruptured?
Severe back pain
Low blood pressure
Increase heart rate

4. Priority Decision: What is the first priority in C.S.'s care?

The prognosis for a ruptured aneurysm is poor, and surgery is done right away. Common open laparotomies, newer minimally invasive techniques, and the insertion of endovascular
stents are all options. When surgery can be postponed, surgical interventions include:
- Strict blood pressure monitoring and a decrease in pulsatile flow.
- Antihypertensive medications, such as nitroprusside, are used to keep systolic pressure between 100 to 120 mm Hg.
- Medications that reduce heart contractility, such as propanolol, to reduce pulse flow.

5. What steps, if any, could have been taken to prevent the rupture of the AAA?
Tobacco products should not be used. Quit smoking or chewing tobacco, and stay away from secondhand smoke.
Maintain a healthy diet. Consume a wide range of fruits and vegetables, whole grains, meat, fish, and low-fat dairy products. Limit salt and avoid saturated and trans fats.
Maintain a healthy blood pressure and cholesterol level. If the doctor has recommended drugs, follow the directions exactly.
Exercise on a regular basis. Aim for at least 150 minutes of moderate aerobic exercise a week. If you haven't been involved in a while, begin slowly and gradually increase your activity
level. Consult the doctor on the types of things that are appropriate for you.

6. What postoperative care will the nurse provide for C.S.?

Monitor Blood Pressure, Pulse, Pulse Oximetry and Respirations
Monitor Temperature
Intravenous Monitoring and Fluid balance
Wound Care
Pain Management
7. Patient-Centered Care: What discharge teaching should be included for this patient after theAAA repair?
 Activity
- Rest when you feel tired. Getting enough sleep will help you recover.
- Every day, try to go for a walk. Start by walking a little more than you did the previous day. Increase the walking distance gradually.
- Avoid strenuous exercises that could strain the incision.
- When coughing or taking deep breaths, place a pillow over the incision. This will help to stabilize the stomach and relieve pain.
- Do the breathing exercises prescribed by the doctor at home. This will aid in the prevention of pneumonia.
Diet
- You will choose to enjoy your regular meal. If you have a stomach ache, eat bland, low-fat foods such as white rice, broiled chicken, bread, and yogurt.
- Consume plenty of fluids (unless your doctor tells you not to).
Medicine
- Your doctor will inform you when and whether you should resume taking your medications. He or she will even advise you on how to take your new medications.
- Take precautions when handling medications. Take pain relievers just as prescribed.
- Take antibiotics exactly as prescribed by the doctor. Do not consider taking them just because you are feeling better. You must complete the whole course with antibiotics.
Incision Care
- Whether you have tape strips on the incision, keep them on for a week or before they come off.
- Every day, wash the area with wet, soapy water and pat it dry. Some cleaning agents, such as hydrogen peroxide, can delay the wound's healing. If the wound weeps or rubs on skin,
cover it with a gauze bandage. Every day, change the bandage.
- Keep the area clean and dry.

8. Priority Decision: Based on the assessment data presented, what are the priority nursing diagnoses? Are there any collaborative problems?
 Decreased Cardiac Output related to alteration in heart rate secondary to abdominal aortic aneurysm as evidenced by cool and clammy extremities, heart rate of 114 bpm and blood
pressure of 88/60 mmHg.
 For Collaborative, the client needs to surgery and medications, because his abdominal aortic aneurysm has already ruptured.